Comprehensive Effects of Occupational Therapy Using Ayres Sensory Integration® in Children With ADHD: A Randomized Controlled Trial

Dear Editor,

We are writing in response to the recently published randomized controlled trial (RCT) by Kaplan Kılıç et al. (2026). We commend the authors for conducting an RCT on Ayres’ Sensory Integration (ASI) for attention deficit hyperactivity disorder (ADHD). However, a more nuanced discussion of its implications and conclusions is required.

Occupational therapists must prioritize evidence demonstrating improvements in function and participation (American Occupational Therapy Association, 2020). Despite its extensive research use, the Bruininks–Oseretsky Test of Motor Proficiency Second Edition (BOT-2) has limited predictive validity for function and participation (Vinçon et al., 2017); impairment-based measures, like BOT-2, rarely correlate with these outcomes in context (Marcotte et al., 2022). The authors measured function and participation with unblinded tools—highly susceptible to nocebo and placebo—so conclusions of effectiveness must be interpreted with caution (Bagnis et al., 2025).

While the authors reported statistically significant change, minimally clinically important differences (MCID) for BOT-2 and Sensory Integration and Praxis Test (SIPT) for function and participation are not established. The findings suggest that ASI changes body structure and function impairments as specifically defined by BOT-2 and SIPT. However, ASI's ability to transfer skills to other environments and generalize to other tasks remains unclear. Future studies should improve clinical applicability by defining MCID thresholds a priori, reporting the proportion of participants achieving these changes, and incorporating ecologically valid measures reflecting function and participation in home, school, and community contexts.

The research design limits the ascription of the reported outcomes to ASI exclusively. While a waitlist control design is understandable as it identifies the largest possible effect, it cannot control placebo, nocebo, or confounding variables (Shadish et al., 2002). Critically, the addendum materials describe intervention activities that are not ASI theoretically required activities (e.g., vestibular, proprioceptive, or tactile activities) and are consistent with active ingredients from other approaches that support skill acquisition and participation. For example, children in this study performed dressing and undressing or task-specific training (e.g., Rameckers et al., 2023). Such practice also requires the child to engage in problem solving, an effective strategy for transfer to performance (e.g., Laverdure & Beisbier, 2021). While the authors conclude that ASI was effective, the presence of confounders requires a nuanced discussion of the results’ implications and conclusions. Future research needs to examine the active ingredients by identifying a priori theoretical mechanisms of change and active ingredients, and documenting treatment dose (intensity, duration, and frequency of vestibular, proprioceptive, or tactile activities) versus activities consistent with known effective approaches for increasing function and participation (Laverdure & Beisbier, 2021).

A greater understanding of optimal assessment and intervention strategies for children with ADHD is needed. Again, we applaud the work of the Kaplan Kılıç team and hope that additional controlled research follows to enhance knowledge of intervention strategies for the spectrum of problems experienced by children with ADHD.